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Dermatology: Managing atopic eczema

17 November 2015

Managing atopic eczema

Content written by Stiefel, a GSK company.

Learning objectives

Following completion of this module you will be aware of:

1) The condition and physiology of atopic eczema

2) The causes and impact of atopic eczema both physically and on quality of life

3) Complete emollient therapy as the basis of treatment for atopic eczema and what this means for the patient

4) Ways that patients can manage their condition more effectively and useful tips and information you can pass onto patients

Introduction

Atopic eczema is a chronic dermatological condition that can have a significant impact on the patient both physically and also in terms of quality of life.1,2 It is a common condition and one that appears to be increasing in prevalence.2 Consequently it places a considerable burden on healthcare resources.1 However, the burden on healthcare and also the impact on patients could be considerably reduced with appropriate management, diagnosis and assessment.3 This module explores atopic eczema and how healthcare professionals can better understand the condition and its management. It also provides a range of tips and advice that can be provided to patients to help improve their own management of atopic eczema.

CPD Question: What impact does atopic eczema have on your current patients?

What is atopic eczema?

CPD Question: What are the main signs of atopic eczema?

Atopic eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that is characterised by red, itchy, sore skin often involving the face, scalp and limbs.1 It is an episodic condition meaning there are periods of remission and then flare ups.1 These flare ups can occur as often as 2-3 times a month.1

Image reproduced with the kind permission of Dr Tim Cunliffe, the Middlesbrough Specialist Skin Service.

Atopic eczema can affect people of any age, although it usually starts in childhood, with around 80% of cases occurring before the age of 5 years.2 Estimates suggest that between 15-20% of children in the UK are affected by atopic eczema, and for adults this figure is between 2-10%.2 There is no difference in the prevalence of atopic eczema based on sex or ethnicity.2

It has been found that atopic eczema often has a genetic component, and if both parents have the condition, then around 80% of their children will also be affected. This figure is in the region of 60% if only one parent has the condition.2

An abnormality in the gene which is important for maintaining the skin barrier has been closely linked to the onset of eczema as this can affect the development of the skin barrier.4 Interactions between those genes responsible for the breakdown of the skin barrier and irritants, such as soap and detergents can trigger eczema to flare up.1 There is also evidence that environmental factors including exposure to pets, house-dust mites, pollen and food allergens may also be involved in the process.2

Although in many cases atopic eczema improves with time, not all children will 'grow out of it'. And whilst there is no cure, people with atopic eczema can lead a normal life with appropriate management of the condition.4

What happens to the skin in atopic eczema?

CPD Question: Briefly describe the breakdown of the skin barrier.

The skin has two main layers - the epidermis and the dermis. The epidermis is the surface layer which itself is composed of several thinner layers. The outer layer of the skin is called the stratum corneum. It is changes to this layer that can lead to a breakdown of the skin barrier causing it to not work as effectively as it should.5 This defective barrier function allows the penetration of irritants or environmental allergens into the skin which triggers an immune or inflammatory response, leading to itching and redness.5

This defective function also leads to increased water loss from the stratum corneum. This in turn causes the corneocytes (the interlocking cells which make up the majority of the stratum corneum) to shrink and then cracks open up between these cells. The result is dry skin, which cannot retain water effectively or prevent irritants or allergens from entering the skin.6 As a consequence, the damage to the skin can prompt the patient to scratch, which causes further skin damage. This is known as the itch-scratch cycle.5

The impact of atopic eczema on your patients...

CPD Question: How many patients are you seeing in your practice for atopic eczema and does this equate to the established prevalence?

Atopic eczema can have a major impact on patients, particularly babies and children, and have negative consequences on their quality of life.1,7,8 For example, an inability to sleep due to severe itching means that schoolwork and home life are disrupted. Additionally, childhood eczema has been shown to have an impact on quality of life greater than or equal to other common childhood diseases such as asthma and diabetes emphasising eczema as being a major chronic childhood disease.8

The physical effects of atopic eczema can include: 1,7,8

  • Painful, itchy rash
  • Skin damage; thickening, oozing, bleeding, cracking and changes in pigmentation
  • Difficulty in wearing some clothes
  • Sleep disturbance and resulting fatigue
  • Avoidance of some activities such as swimming

Among the psychosocial effects are: 1,7,8

  • Social isolation / stigmatisation
  • Restricted participation in sports and group activities
  • Depression
  • Fearfulness or anxiety
  • Low self-esteem, teasing or bullying
  • Time off work or school

...and your practice

Atopic eczema places a considerable burden on healthcare resources. It accounts for 30% of dermatological consultations in general practice and its prevalence is increasing.3

Atopic eczema affects 15-20% of school-aged children,9 which equates to approximately 1.75 million GP consultation per year - a figure which could be almost halved through improvements in:3

  • Management
  • Diagnosis
  • Assessment

What are the treatment guidelines for atopic eczema?

NICE guidance suggests that healthcare professionals take a holistic approach when assessing atopic eczema, taking into account the severity of the condition and the impact on quality of life.1 The guidance states that emollients should form the basis of management and should always be used even when the atopic eczema is clear.1

It is recommended that a 'complete emollient therapy' (CET) approach is taken for the management of atopic eczema. CET includes the frequent and generous application of emollient creams or lotions, with 250g per week being a commonly recommended amount for children and 600g for adults.9 For CET to be most effective it is also vital that patients and their carers are advised in the use of emollient washes or soap substitutes.10 Healthcare professionals should recommend these products because regular soaps, shampoos, bath and shower gels, and detergents can dry out the skin and so should be avoided at all times.5,10

It is often the case that different parts of the body are affected by differing severities of eczema. It is important that each area of the body is managed appropriately and treatments should be stepped up or down as required, although leave-on emollients and emollient washes should continue to be used regardless of the severity of the condition - even when the skin is clear.1

The illustration below shows the treatment gudielines for differing levels of atopic eczema as recommended by NICE.1

Images reproduced with the kind permission of Dr Tim Cunliffe, the Middlesbrough Specialist Skin Service.

To achieve optimal effect, NICE recommends:1

  • Leave-on emollients and emollient washes should be used for washing, bathing and moisturising in all levels of eczema, even when the skin is clear
  • Emollients should be used more frequently and in larger amounts than other treatments
  • Emollients should continue to be used even when other treatments are co-prescribed
  • Prescribing 250-500g of leave-on emollient per week

What is the right emollient for a patient?

CPD Question: What criteria do you currently use to select an emollient for your patients?

Emollients are the mainstay of treatment for all patients with atopic eczema as they can help:4,11,12

  • Skin to retain water
  • Moisturise dry skin
  • Restore and maintain the skin's suppleness
  • Ease itching
  • Reduce scaling and improve appearance
  • Protect the skin

As complete emollient therapy (CET) is the recommended basis for the treatment of eczema, this means patients should be advised to regularly apply generous amounts of a leave-on emollient moisturiser. Recommending the use of emollient wash products (also known as soap substitutes) is an important part of CET.10 The everyday use of regular soaps, shampoos and shower gels can remove the surface layer of natural oils on the skin, making it dry and more susceptible to eczema.5 Specially formulated emollient washes can be used instead of conventional soap for handwashing and bathing to help the skin retain moisture and suppleness.4

Emollient products can be formulated with a variety of ingredients.13 It is important to select an emollient that is both acceptable to the patient and one that has ingredients suitable for purpose. The ingredients in emollients can include:13

Occlusives: These are ingredients that help form a layer on the skin, creating a barrier to prevent water loss and evaporation. Among occlusives used are light liquid paraffin, white soft paraffin, and petroleum jelly. Such ingredients have been shown to reduce transepidermal water loss (TEWL) by nearly 100%.13

Humectants: Humectant ingredients provide moisturisers with their primary hydrating effect. They attract and hold water in the skin, either by drawing it up from the dermis to the epidermis or from the environment into the epidermis.13 Because they can cause evaporation, they need to be combined with occlusive agents to decrease or prevent TEWL.13

There is a range of emollients available for the treatment of eczema, including lotions, creams and ointments and these vary in the amount of oil they contain.11 Other ingredients may be added to provide additional properties, such as an anti-infective or antibacterial effect.14 However, some formulations may contain fragrances, emulsifiers, and other 'inactive ingredients' that may cause irritation and potentially contribute to poor barrier function.13

To improve compliance, patients should be given the opportunity to try a variety of emollients to find one they find acceptable, depending on the condition of their skin and appropriate effect.1

What is infected eczema and how should it be treated?

CPD Question: What are the signs that atopic eczema has become infected?

Because of damage to the surface of the skin, a common complication of atopic eczema is bacterial infection known as staphylococcus aureus.1 This can lead to a worsening of inflammation or the development of weeping skin, pustules or crusts. Other symptoms of infected atopic eczema may include the eczema failing to respond to treatment, rapidly worsening eczema, fever and malaise.1

Image reproduced with the kind permission of Dr Tim Cunliffe, the Middlesbrough Specialist Skin Service.

Patients should be encouraged to seek medical advice when eczema becomes infected.15 Treatment of infected eczema in children should include a wash emollient and a leave-on emollient, systemic antibiotics such as flucloxacillin or erythromycin may be used, or a topical antibiotic if the infection is localised.1

What are the complications of infected eczema and when should you refer to a specialist?

CPD Question: Who are the specialists in your area who you could refer patients to?

If atopic eczema becomes infected there is an increased possibility of serious complications, particularly of eczema herpeticum.15 In such instances and also in cases where the atopic eczema is not responding to optimum topical therapy or is having a severe, negative impact on a patient's quality of life, then referral to a specialist is advised.1

Refer for urgent same-day specialist dermatological advice:1
It is important that patients and parents of children with atopic eczema are offered advice on recognising the worsening of symptoms and the signs of eczema herpeticum. Eczema herpeticum is a potentially serious viral infection caused by Herpes simplex virus HV1, the virus that causes cold sores.1 Patients with atopic eczema may experience ordinary cold sores, but they should look for additional signs, including:1

  • Areas of rapidly worsening, painful eczema
  • Possible fever, lethargy or distress
  • Clustered blisters that look like early-stage cold sores
  • Uniform, punched-out erosions (usually 1-3mm in diameter) which may coalesce

If eczema herpeticum is suspected, the patient should be referred for same-day specialist dermatological advice and may require antiviral treatment and/or hospital admission. If it is apparent in areas of skin around the eyes, both same-day specialist dermatolgical and opthalmological advice should be sought.1

Refer urgently (within 2 weeks) for specialist dermatological advice if:1

  • The atopic eczema is severe and has not responded to optimum topical therapy after 1 week
  • Treatment of bacterially infected atopic eczema has failed

Referral for specialist dermatological advice is recommended if:1

  • The diagnosis is, or has become, uncertain
  • Management has not controlled the atopic eczema satisfactorily based on a subjective assessment by the child, parent or carer (for example, the child is having 1-2 weeks of flares per month or is reacting adversely to many emollients)
  • Atopic eczema on the face has not responded to appropriate treatment
  • The child or parent/carer may benefit from specialist advice on treatment application (for example, bandaging techniques)
  • Contact allergic dermatitis is suspected (for example, persistent atopic eczema or facial, eyelid or hand atopic eczema)
  • The atopic eczema is giving rise to significant social or psychological problems for the child or parent/carer (for example, sleep disturbance, poor school attendance)
  • Atopic eczema is associated with severe and recurrent infections, especially deep abscesses or pneumonia

Refer for specialist psychological or other advice if:1

  • The atopic eczema has responded to optimum management but the impact on quality of life and psychological wellbeing has not improved
  • Food allergy is suspected in cases of moderate or severe atopic eczema, specialist investigation and management should be sought
  • A child with atopic eczema fails to grow at the expected trajectory, refer for specialist advice relating to growth

Tips for managing atopic eczema

CPD Question: Considering these tips, what advice and suggestions could you give to patients in addition to that which you are already providing?

Complete emollient therapy is the basis for successful management of atopic eczema.1,2,10 This involves patients using leave-on emollients and soap substitutes for washing. Patients should be advised to use their emollient all of the time, even if the skin is clear and they are not experiencing symptoms.

Healthcare professionals should give clear instructions on how patients manage flares according to the stepped-care plan, and prescribe treatments that allow children and their parents or carers to follow this plan. Whatever additional treatments may be prescribed, CET should be maintained.1,10

Here are some useful tips which can be passed onto patients to help improve their eczema self-management.10,11

Using emollients:

  • Have supplies of emollient easily available and keep separate stocks at home, work or school
  • Moisturise skin as often as possible, ideally at least 2-3 times each day, and whenever the skin appears dry
  • Apply emollient liberally and do not rub it in - instead, leave it to soak into the skin
  • Smooth emollient into the skin in the same direction as hair growth
  • After a bath or shower, gently pat the skin dry and apply the emollient while the skin is still moist to keep the moisture in
  • Don't put fingers into an emollient pot - use a spoon or pump dispenser instead, as this reduces the risk of infection - and never share emollient with other people
  • During a flare-up, apply generous amounts of emollient more frequently
  • Wash and bathe with an emollient wash instead of regular soap - avoid soap, bubble baths, shower gels and detergents

Summary of management

Atopic eczema is a condition, that with appropriate treatment, need not stop a patient from leading a normal life.4 The management of atopic eczema is centred around the identification and avoidance of triggers, and a stepped treatment plan that has complete emollient therapy - with the use of both leave-on emollients and emollient washes - at its core.4,10 Help your eczema patients by educating them on condition management and prescribing them both a cream and wash emollient for a complete emollient therapy regimen.

Useful resources:

National Eczema Society: www.eczema.org

British Skin Foundation: www.britishskinfoundation.org.uk

British Association of Dermatologists: www.bad.org.uk

References:

  1. NICE Clinical Guideline 57. Atopic eczema in children: Management of atopic eczema in children from birth up to the age of 12 years. December 2007. Available at: https://www.nice.org.uk/guidance/cg57. Last accessed 22.10.15.
  2. NICE Clinical Knowledge Summaries. Eczema - atopic. July 2015. Available at: http://cks.nice.org.uk/eczema-atopic#!background. Last accessed 22.10.15.
  3. NICE Clinical Guideline 57. Atopic eczema in children. Costing report. Available at: https://www.nice.org.uk/guidance/cg57/resources/costing-report-196570765. September 2008. Last accessed 22.10.15.
  4. British Association of Dermatologists Patient Leaflet. Atopic Eczema. April 2013. Available at: http://www.bad.org.uk/for-the-public/patient-information-leaflets/atopic-eczema. Last accessed 22.10.15.
  5. Cork MJ, Danby S. Skin barrier breakdown: a renaissance in emollient therapy. Br J Nursing 2009; 18(14): 872-877.
  6. Cork MJ. The importance of skin barrier function. Journal of Dermatological Treatment 1997; 8:S7-13.
  7. Hoare C et al. Systematic review of treatments for atopic eczema. Health Technology Assessment 2000; 4: (37).
  8. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract 2006; 60(8): 984-992.
  9. Guidelines for the management of atopic eczema. Primary Care Dermatology Society & British Association of Dermatologists. Available at: http://www.pcds.org.uk/images/stories/pcdsbad-eczema.pdf. Last accessed 22.10.15.
  10. Clark C. Atopic eczema management. Clinical Pharmacist 2010; 2:291-298.
  11. NHS Choices. Atopic eczema. Treatment. Available at: http://www.nhs.uk/Conditions/Eczema-(atopic)/Pages/Treatment.aspx. Last accessed 22.10.15.
  12. NHS Choices. Emollients. Introduction. Available at: http://www.nhs.uk/conditions/Eczema-(atopic)/Pages/Introduction.aspx. Last accessed 22.10.15.
  13. Downie JB. Understanding moisturizers and their clinical benefits. Practical Dermatology for Pediatrics September/October 2010. 19-22. Available at: http://bmctoday.net/practicaldermatologypeds/2010/10/. Last accessed 09.09.15.
  14. Moisturisers and moisturising bath additives or washes: Net Doctor. Last updated 09.07.14. Available at: http://www.netdoctor.co.uk/skin_hair/eczema_moisturisers_003761.htm Last accessed 22.10.15.
  15. NHS Choices. Atopic eczema. Complications. Available at: http://www.nhs.uk/Conditions/Eczema-(atopic)/Pages/Complications.aspx. Last accessed 22.10.15.

Date of preparation: November 2015. CHGBI/CHOIL/0126/15.